Transcript Marketing Evidence Evans

Marketing “evidence” to healthcare consumers:
Applying social marketing to evidence about the
harms and benefits of pharmaceuticals
Presented by
W. Douglas Evans, Ph.D.
Lauren McCormack, Ph.D., M.S.P.H
Presented at
Agency for Healthcare Research and Quality Conference:
Communicating Harms and Benefits of
Prescription Drugs to Healthcare Consumers
Rockville, MD, September 13, 2006
RTI International ■ 701 13th Street, NW ■ Suite 750
Phone 202-728-2058
Fax 202-728-2095
■
Washington, DC 20005
E-mail: [email protected]
RTI International is a trade name of
Research Triangle Institute
What is Social Marketing?

2
Andreasen (1995) defines social marketing as “the
application of proven concepts and techniques drawn
from the commercial sector to promote changes in
diverse socially important behaviors such as drug
use, smoking, sexual behavior...This marketing
approach has an immense potential to affect major
social problems if we can only learn how to harness
its power…”
Theoretical Foundations
3

Behavior change theory
 SCT (Bandura), TPB (Ajzen), Transtheoretical
Model (Prochaska)

Message theory
 Elaboration Likelihood (Petty, Cacioppo)

Exposure theory
 (Hornik)

Marketing theory
 (Kotler, Zaltman, and many others)
3 Basic Approaches

4
How to maximize audience exposure to messages?

Channels

Leverage

“Beg” for it – PSAs

“Buy” it – paid promotion (e.g., advertising)

“Borrow” it – earned media coverage

Most campaigns represent some combination
Social Marketing Strategies

Audience Segmentation

Targeting

Tailoring

Marketing Strategy

5

4 Ps – Place, Price, Product, Promotion

Aspiration or social modeling

Branding
Create a social movement
Social Marketing Wheel
Source: NCI 2002
6
Evidence of Effectiveness
7

Bottom line: Small effect sizes for social marketing,
but potentially large population impacts

From 1999-2002, prevalence of smoking in young
people in the US decreased from 25.3% to 18%, and

American Legacy Truth campaign was responsible for
about 22% of that decrease

Small effect by clinical standards, but approximately
300,000 fewer youth smokers in the US
Evidence of Effectiveness (2)
8

Snyder & Hamilton (2002) reviewed recent US mass media
campaigns: Average campaign accounted for 9% of favorable
changes in health risk behavior, with highly variable results

“Non-coercive” campaigns (simply delivering health information)
accounted for about 5% of the observed variation in behavior

Grilli et al. (2000) studied 17 recent European campaigns on
several topics (HIV, nutrition, etc.) and found behaviors requiring
one-time (or few) change are easier to promote than those that
must be repeated and maintained.

Hornik (1997) and Snyder et al. (2003): Some examples
(breastfeeding, vitamin A supplements, switching to 1% milk)
have shown greater effect sizes and long-term maintenance.
Portion of Decline in Youth Smoking
Attributable to truth®


Approximately
22% of total
decline in youth
smoking
attributable to the
“truth” campaign
Represents
roughly 300,000
fewer youth
smokers as a
result of “truth”
30%
25%
28.0%
23.7%
26.8%
22.0%
25.3%
19.6%
22.6%
20%
20.3%
18.0%
15%
Trend in actual smoking
10%
Predicted trend if truth did not exist
5%
0%
1997
9
1998
1999
2000
2001
2002
Social Marketing in Health Care

Some efforts to change consumer behavior, primarily
through risk communication

10
Good examples from prostate & breast cancer
screening (McCormack et al., in press)

Very little published research on social marketing to
change health care provider behavior

Recent work on understanding marketing by
pharmaceutical firms to psychiatrists & physicians
(Steinman, Bero et al., 2006)
Many Opportunities for
Social Marketing in Health Care…

AHRQ purposes:

Synthesize knowledge: Evidence-based Practice Centers
systematically review published & unpublished scientific evidence
 Generate knowledge: DEcIDE Research Network studies new
scientific evidence and analytic tools in an accelerated and practical
format.
 Translate knowledge: The John M. Eisenberg Clinical Decisions
and Communications Science Center compiles the research results
into a variety of useful formats for stakeholders.

Target Populations:
Elderly – Medicare/Medicaid (SCHIP)
 Pregnant women and young children
 People with disabilities

11
Social Marketing Opportunities

All of these purposes and populations are currently
targets of social marketing efforts by major funders
(e.g., CDC, NIH, foundations)

Significant opportunities to apply social marketing

Goal is to identify social marketing strategies that can
be translated to health care settings


12
Reinforcement of messages/campaigns
Which ones seem most readily translatable?
What Strategies & Tactics
Work in Social Marketing?
13

Countermarketing

Argument credibility and likeability

Theory-based change models

Social modeling & behavioral alternatives

Risk communication (with certain populations)
What Does NOT Work in Social Marketing

Negative messaging can be ineffective with specific
audiences (young people)

High cost tradeoffs (loss of immediate, desirable
lifestyle options in return for long-term health gains)

Ambiguous messages (do this, except when…)


14
Evidence-based messages need to have clear
associated behaviors
Low exposure
Global Social Marketing Challenges
15

Increase in health issues competing for public
attention (tobacco, obesity, drug abuse, HIV/AIDS)

Busy lifestyles, people’s time limitations, technology

Cluttered media environment for health information

Increase in the number and type of communication
channels, including the Internet

Consumers & practitioners: Demands on time,
multiple education/information sources, changing
practice guidelines, fads in health promotion
Specific Challenges with
Health Care Consumers
16

Informed decision making (or shared decision making) to
address scientific uncertainty

Patient behavior change can be talking to your provider about
pros and cons of different decisions

How to give providers discussion points to raise with patients?

How to give providers easy access to evidence & discussion
points at point of patient contact (e.g., PDAs, pocket info)

After the discussion, the decision may be to do nothing (e.g., not
get tested, at least not now)

Encourage additional learning about the clinical area
Case Studies
17

Following slides offer 4 brief examples from
successful social marketing efforts that illustrate key
principles of what works

Each example focuses on possible applications in
health care
Case Study 1: Countermarketing
18

Counter-marketing is a strategy to deliver information to
counter the effects of marketing by companies with
competing interests (e.g., tobacco, pharmaceuticals)

Has been widely used in public health to promote
population-level health behavior change and prevention
(e.g., smoking)

Competition between messages: Countermarketers take
away “market share” by providing more compelling facts,
information, imagery (rational and affective appeals)

Recently, counter-marketing has been used to reach
practitioners such as psychiatrists to counter
pharmaceutical industry misinformation
Countermarketing - Competition
19

In tobacco control, countermarketing “brands”
encourage non-smoking lifestyle (Evans et al., 2005)

Use persuasive imagery to sell non-smoking, counter
to imagery used by industry to sell smoking as
socially desirable

Countermarketers compete with tobacco industry
marketing to take away “market share”

Encourage adoption of alternative behaviors to take
away “market share” from the smoking behavior
Rebellion against industry
20
Potential Lessons for Health Care
21

Countermarketing offers strategies for dissemination of
best practices (e.g., patient-provider communication)

Evidence of success in delivering rational arguments
(tobacco use risks) with credible messages

Countermarketing could deliver credible science-based
information to consumers to counter inaccurate messages
or promote informed decisions (e.g., Medicare Part D)

Countermarketing could counter misleading
pharmaceutical marketing to practitioners and reinforce
other information such as CME, conferences, publications
Case Study 2: Credibility & Likeability
22

Message theory suggests people must engage in
“elaboration” (agree with a message’s arguments) for
persuasion to occur (Petty & Cacioppo 1986)

Elaboration has both cognitive (rational) and affective
(emotional) aspects – credibility & likeability

Effective social marketing campaigns use targeted
and/or tailored messages to affect behavioral factors
Effectiveness of Targeted Messages
23

Evidence that targeted message strategies used in
countermarketing influence specific attitudes and beliefs.

Sly et al. (2002) found teens with high levels of anti-tobacco
industry attitudes promoted by the Florida TRUTH campaign
were 4 times less likely to initiate smoking and more than 13
times less likely to become established smokers.

Ohio stand campaign (Hersey, et al., 2006) followed youth over
an 18 month period and found reduced likelihood of initiation
among 15-17 year olds that self-reported campaign awareness.

Consortium to Lower Obesity in Chicago Children (CLOCC) has
developed a clinic- and community-based intervention – 5-4-3-21 Go! – that targets specific nutrition and physical activity
behaviors for multicultural audiences (Evans et al., in press)
The stand Campaign
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stand Awareness and Smoking Uptake
Y1 Never Smokers who
Tried Smoking at Y3

Longitudinal Survey: Time
1 (Y1) - Time 3 (Y3)
8%

Never Smokers at Y1
6%

Aware of stand at Y1 Less likely to try smoking
at Time 3
10%
4%
9.5%
6.5%
2%

6.5% vs. 9.5% or
0%

44% less uptake
Aware of
stand
25
Not Aware
Potential Lessons for Health Care
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
Social marketing messages for health care (e.g.,
immunization, screening) should be delivered to
consumers by trusted sources that enhance credibility

Consumers are more likely to change behavioral
precursors and health care behaviors if messages are
credible, likeable, and have source credibility.

Providers have a unique opportunity to serve as
trusted sources for some target audiences (providerto-patient population relationship may be important in
multicultural, low income, etc., settings)
Case Study 3: Theory-based
Behavior Change Models
27

Social marketers use theory to identify behavioral determinants
that can be modified.

For example, social marketing aimed at obesity might use theory
to identify connections between behavioral determinants of poor
nutrition, such as:
 Eating habits within the family,
 Availability of food with high calorie and low nutrient density
(junk food) in the community
 Glamorization of fast food in advertising

Social marketers use such factors to construct conceptual
frameworks that model complex pathways from messages to
changes in behavior
Example Behavior Change Model
1. Social Marketing
Initiatives
 National 5-A-Day
campaign
 Messages for
African Americans
& Hispanics
 Health promotion
value of fruits and
vegetables
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2. Exposure to
5-A-Day
Message
 Audience
awareness
 Message
receptivity
3. Knowledge, Attitudes,
and Beliefs
• Belief in health promotion
value of fruits and
vegetables
• Attitude that consuming
more fruits and
vegetables is good
• Intention to consume
more
4. Behavior
 Consuming
5 servings
of fruits and
vegetables
every day
Promotion of Evidence-based Nutrition & PA
Using Theoretical Framework
29
Example Theoretical Frameworks
30

Social cognitive theory (Bandura 1986): Modeling a positive,
nonsmoking lifestyle encourages emulation

Countermarketing campaigns can effectively project images of
socially desirable behavioral choices (lifestyle)

Social images projected by Legacy Truth campaign are of
coolness & popularity of non-smoking (Evans, et al. 2005)

Science-based messages presented in appealing, culturally
appropriate way are better received (Evans et al., in press)

Additional evidence from public health:
 Hornik et al. (2003): ONDCP anti-drug campaign
 Huhman et al. (2004): VERB: It’s What You Do campaign
Potential Lessons for Health Care
31

Health care consumer behavior can be changed
through underlying behavior change principles

For example, health care choices can be portrayed as
socially desirable while also providing accurate,
science-based facts and information

Science-based information can be made appealing

Opportunity to merge behavior change theory and
health science dissemination & translation fields
Case Study 4: Risk Communication
About Pharmaceuticals
32

Recent research on marketing/promotion of gabapentin (antiepileptic drug (AED)) to prescribers (psychiatrists) & consumers
(mood disorder patients)

Settlement between Pfizer (former Warner-Lambert) and NAAG
provides insight into industry marketing (document discovery)

Promotion generally ignored evidence base for appropriate
prescription, put consumers at undue risk

How can social marketing - dissemination of evidence to
prescribers and consumers - counteract this?
Gabapentin Marketing

Continuing Medical Education


Advisory Boards & Consultant Meetings


Informal exploratory & concept testing “research”
Research Strategy & Publications

33
Warner-Lambert used CME events at which
speakers could communicate directly to physicians
Disseminate through publication as promotion tool
Evidence-based AED Dissemination Model
34
Potential Lessons for Health Care
35

Pharmaceuticals using many of same marketing strategies
proven effective in social marketing

Countermarketing could target both physicians and
consumers

Physicians reached through dissemination of evidencebased drug information: CMEs, conferences, Web-based
dissemination, pocket cards, PDA applications

Publication of evidence base on gabapentin & drug class

Consumers reached through mass media (Web),
physician-patient interaction (mediated communication)
Some Principles of Effective
Communication
36

Personalize risk data -- use stories, narratives, and
anecdotes

Use graphics and other pictorial materials to clarify
messages

Be sensitive to local norms, such as culture, speech, and
dress

Use a variety of approaches such as written, oral, and
electronic

Use clear, non-technical “plain” language appropriate to
the target audience (www.plainlanguage.gov)
Conclusion: Implications of Social Marketing
for Health Care Practice
37

Social marketing can be useful in health care practice

Evidence on social marketing suggests underlying
principles can influence health care consumer
decision making through multiple strategies

Health care setting provides a unique opportunity to
reinforce messages aimed to consumers through brief
counseling

As a trusted source, practitioners’ reinforcement of
social marketing messages adds value beyond the
effects of mass communication
Questions/comments?

38
W. Douglas Evans, Research Triangle Institute,
[email protected], 202-728-2058